Corrective Action Plans

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Finding: 2022-004: Material Weakness in Internal Controls over Compliance – Single Audit Report Submission Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 CCS will work with its audit firm to ensure the audit is submitted in a timely manne...
Finding: 2022-004: Material Weakness in Internal Controls over Compliance – Single Audit Report Submission Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 CCS will work with its audit firm to ensure the audit is submitted in a timely manner. Proposed Completion Date: 6/30/24
Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be mai...
Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be maintained. Anticipated Completion Date: 12/31/2022
Finding 392162 (2022-003)
Material Weakness 2022
Forth
OR
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there wer...
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there were insufficient internal controls over invoices submitted for cost reimbursement related to federal grants as invoices were created and approved by one individual. While the internal controls were insufficient, our sample of invoices did not contain errors or undocumented amounts. It was noted during the audit that there were insufficient internal controls over required federal financial reports as federal financial reports were created and approved by the one individual. While the internal controls were insufficient, our sample of federal financial reports did not contain errors or undocumented amounts. It was also noted that there were three first-tier subawards entered into during 2022 greater than $30,000 that were not reported to the Federal Funding Accountability and Transparency Act Subaward Reporting System. Recommendation: The Organization should establish written policies and procedures regarding federal financial reporting and invoicing for cost-reimbursement related to federal grants which include proper segregation of duties. Additionally, the Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Action Taken: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Senior Finance Manager in late 2022 and an Accounting Associate in early 2023 to allow for further segregation of duties. Effective 2023, the Senior Finance Manager prepares the invoices and financial reports related to federal grants for review and approval by the Director of Finance and Operations. Additionally, there are now static financial reports and supporting documentation to substantiate each billing invoice. We will update the financial policies and procedures to reflect these enhanced internal controls over reporting and invoicing by March 2024. Policies and procedures will be revised as needed to ensure the guide is current. Responsible Official: Gina Avalos-Limardo, Director of Finance & Operations Planned Completion Date: March 31, 2024
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will establish a debt service fund in accordance with the letter of conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will obtain required insurance coverage as noted in the Letter of Conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward including providing required financial information the USDA. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Has been implemented.
Finding 392118 (2022-002)
Material Weakness 2022
The county added information to the Payment Request Form to make sub recipients aware that their organization along with any respective Contractors need an active UEI and must be registered in SAM.
The county added information to the Payment Request Form to make sub recipients aware that their organization along with any respective Contractors need an active UEI and must be registered in SAM.
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
To fortify our internal controls over financial reporting, we will introduce new software to streamline data management and reporting processes, ensuring both accuracy and efficiency. Concurrently, we will refine our internal workflows, introducing comprehensive procedural guides to standardize oper...
To fortify our internal controls over financial reporting, we will introduce new software to streamline data management and reporting processes, ensuring both accuracy and efficiency. Concurrently, we will refine our internal workflows, introducing comprehensive procedural guides to standardize operations and enhance transparency across all departments. Additionally, we'll implement a centralized repository for document storage with stringent retention policies to uphold organized and accessible record-keeping. Finally, we commit to conducting regular, rigorous reviews of financial information by designated personnel, enabling timely identification and resolution of any discrepancies, thereby reinforcing our control environment and safeguarding the integrity of our financial reporting system.
March 27, 2024 2022-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Control: The Consortium did not provide documentation of eligibility for each participant selected for testing. Planned Corrective Action: We agree with the finding. The consortium recognizes the impor...
March 27, 2024 2022-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Control: The Consortium did not provide documentation of eligibility for each participant selected for testing. Planned Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other employee as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January, 2024 Respectfully, Shamar Herron
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Management concurs with this finding. Management has focused its attention on both the determination and designation of key personnel within a contract as well as the ongoing compliance of key personnel designations. Management has implemented control provisions to highlight and approve future key p...
Management concurs with this finding. Management has focused its attention on both the determination and designation of key personnel within a contract as well as the ongoing compliance of key personnel designations. Management has implemented control provisions to highlight and approve future key personnel designations within future contracts. Further, a semi-annual review process will be undertaken to review and document ongoing contractual compliance which will include reference to and consideration of key personnel designations.
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
Finding 390302 (2022-001)
Material Weakness 2022
Finding 2022-001: Material Weakness - Internal Control Over Financial Reporting Condition: A number of adjustments were required to report Unitrans' financial statements in accordance with generally accepted accounting principles (GAAP). The books were not in balance at the start of the audit, and f...
Finding 2022-001: Material Weakness - Internal Control Over Financial Reporting Condition: A number of adjustments were required to report Unitrans' financial statements in accordance with generally accepted accounting principles (GAAP). The books were not in balance at the start of the audit, and fieldwork was delayed as a result. Recommendation: For the year ended June 30, 2021 and 2022, Unitrans put together its own trial balance in accordance with GAAP but some assistance was still required during the audit to ensure completeness of financial reporting. We had recommended in prior audits that Unitrans' management work with ASUCD and UCD finance staff to develop and update a more thorough self-balancing chart of accounts with names that are consistent with the audited financial statements that captures all of Unitrans' financial activity. We noted some progress made in this area as separate Unitrans funds have been created by ASUCD for recording student fee revenue. However, there is still work needed to ensure all accounts balance. Prior to the audit, reconciliations should be done to ensure all activity have been properly recorded and included in the trial balance. We also recommend Unitrans' management work with ASUCD and UCD finance staff to develop a process to ensure all of Unitrans' operating and capital transactions are identified, recorded and correctly classified as required by generally accepted accounting principles prior to the start of the audit. Corrective Action: ASUCD-Unitrans accepts the recommendation as stated. ASUCD-Unitrans notes that this is a repeat finding from the prior fiscal year (Finding 2020-001 and 2021- 001). The recommended action is currently in progress. UC Davis has been working for two years on a comprehensive conversion of its financial accounting (cash management, accounts receivable, general ledger, and fixed assets), procurement, and project/grant accounting systems. This conversion, named Aggie Enterprise, now has an estimated go-live date of January 2, 2024. Unitrans management has provided an assessment of our financial accounting and reporting needs, including the need for a complete, selfbalancing chart of accounts, pursuant to the prior-year Findings 2020-001 and 2021-001 outlined below. Person Responsible: Teri Sheets, Assistant General Manager-Administration; tmsheets@ucdavis.edu Timeframe for Completion: Because the University’s system conversion is not expected to go live until January 2024, we expect to resolve this and prior-year findings in the fiscal year starting July 1, 2024.
Corrective action planned: Educate and/or replace employee responsible for preparing RD Form 442-3 – Balance Sheet for USDA reporting. Increase internal control with Chief Executive Officer review of financial reporting. Anticipated completion date: August 3, 2023 Contact person responsible for c...
Corrective action planned: Educate and/or replace employee responsible for preparing RD Form 442-3 – Balance Sheet for USDA reporting. Increase internal control with Chief Executive Officer review of financial reporting. Anticipated completion date: August 3, 2023 Contact person responsible for corrective action: Mia Amore Talon, Chief Financial Officer
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.
View Audit 300148 Questioned Costs: $1
Finding Number: 2022-001 Condition: The original SEFA prepared for audit purposes did not include all federal expenditures that should have been reported under ALN 66.443. Planned Corrective Action: All programs that have both Federal and State/Local funding will be examined to ensure correct expend...
Finding Number: 2022-001 Condition: The original SEFA prepared for audit purposes did not include all federal expenditures that should have been reported under ALN 66.443. Planned Corrective Action: All programs that have both Federal and State/Local funding will be examined to ensure correct expenditure by funding source is properly recorded. Contact person responsible for corrective action: Curt A. Reppuhn, CPA Deputy Comptroller Anticipated Completion Date: Fiscal Year Ended June 30, 2023
The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.
The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.
Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Act...
Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all vouchers are reviewed by a secondary individual, all supporting backup is maintained for each claim, and all payroll amounts agree to approved contracts. Anticipated Completion Date: April 2024
View Audit 298779 Questioned Costs: $1
Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate...
Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate internal controls to ensure payroll costs and invoice allocations are properly calculated. Responsible Individuals: Robben Luhning and Susan Koesterman. Corrective Action Plan: During 2022, a new payroll system was implemented that should rectify the issue. Anticipated Completion: December 31, 2023.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.
View Audit 298608 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is respons...
Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.
View Audit 298608 Questioned Costs: $1
Finding 385640 (2022-006)
Material Weakness 2022
Corrective Action Planned: Information received from Paymode is not always clear and concise as to what payment is for. We will do our best to comply. Anticipated Completion Date: Unknown Name of Contact Person Responsible for Corrective Action: Ashly Tingle, Comptroller
Corrective Action Planned: Information received from Paymode is not always clear and concise as to what payment is for. We will do our best to comply. Anticipated Completion Date: Unknown Name of Contact Person Responsible for Corrective Action: Ashly Tingle, Comptroller
Reporting Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: ...
Reporting Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The amounts reported as expended in the current period and cumulative expenditures for the award did not agree with the amounts supported by the City’s accounting records. Corrective Action Plan: The City will thoroughly review the Project and Expenditure Report before submission. Subsequent reporting for this award corrected the amounts previously reported. Responsible Individuals: Dustin Scott, City Administrator Anticipated Completion Date: December 31, 2023
Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery F...
Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: During the course of the engagement, it was noted that the City has no formal review process for the allocation of payroll costs to federal awards, which could result in a material misstatement of the City’s schedule of expenditures of federal awards. Corrective Action Plan: The City will review its internal control processes over compliance to ensure that payroll costs allocated to federal awards are adequately reviewed. Responsible Individuals: Dustin Scott, City Administrator Anticipated Completion Date: December 31, 2023
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